Outcomes of Ludloff osteotomy for HAV

NewsBot · Mar 4, 2008

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Intermediate-Term Results of the Ludloff Osteotomy in One Hundred and Eleven Feet.Trnka HJ, Hofstaetter SG, Hofstaetter JG, Gruber F, Adams SB Jr, Easley ME.
J Bone Joint Surg Am. 2008 Mar;90-A(3):531-539.

BACKGROUND: The modified Ludloff proximal first metatarsal osteotomy is indicated for the surgical correction of moderate-to-severe hallux valgus deformity associated with metatarsus primus varus. We report the intermediate-term results of this procedure.

METHODS: Ninety-nine patients (111 feet) with a mean age of fifty-six years underwent a modified Ludloff proximal first metatarsal osteotomy and a distal soft-tissue procedure at two institutions for the treatment of a moderate-to-severe hallux valgus deformity. The American Orthopaedic Foot and Ankle Society score and weight-bearing radiographs of the foot were assessed preoperatively and after a mean duration of follow-up of thirty-four months. Clinical and radiographic outcome was also compared between younger and older patients, with the arbitrarily chosen age of sixty years dividing the two groups.

RESULTS: The mean American Orthopaedic Foot and Ankle Society score improved significantly (p < 0.0001) from 53 points preoperatively to 88 points at the time of the most recent follow-up. The mean American Orthopaedic Foot and Ankle Society score for patients who were sixty years of age or less was significantly higher than that for patients who were more than sixty years of age (91 compared with 83 points; p = 0.0057). The mean hallux valgus angle decreased significantly from 35 degrees preoperatively to 9 degrees at the time of the most recent follow-up (p < 0.0001), and the mean intermetatarsal angle decreased significantly from 17 degrees to 8 degrees (p < 0.0001). All osteotomy sites united without dorsiflexion malunion but with a mean first metatarsal shortening of 2.2 mm.

CONCLUSIONS: To our knowledge, the present report describes the largest cohort of patients undergoing a modified Ludloff osteotomy for the correction of hallux valgus deformity that has been reported in the literature. Our intermediate-term results demonstrate that the procedure achieves significant correction of moderate-to-severe hallux valgus deformity, significant reduction in forefoot pain, and significant improvement in functional outcome. Patients with an age of sixty years or less appear to have a more favorable outcome
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Admin2 · Mar 4, 2008

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NewsBot · May 30, 2013

Additional surgical factors affecting the recurrence of hallux valgus after Ludloff osteotomy
G. W. Choi et al
Bone Joint J 2013;95-B:803–8.

We reviewed 91 patients (103 feet) who underwent a Ludloff osteotomy combined with additional procedures. According to the combined procedures performed, patients were divided into Group I (31 feet; first web space release), Group II (35 feet; Akin osteotomy and trans-articular release), or Group III (37 feet; Akin osteotomy, supplementary axial Kirschner (K-) wire fixation, and trans-articular release). Each group was then further subdivided into severe and moderate deformities.

The mean hallux valgus angle correction of Group II was significantly greater than that of Group I (p = 0.001). The mean intermetatarsal angle correction of Group III was significantly greater than that of Group II (p < 0.001). In severe deformities, post-operative incongruity of the first metatarsophalangeal joint was least common in Group I (p = 0.026). Akin osteotomy significantly increased correction of the hallux valgus angle, while a supplementary K-wire significantly reduced the later loss of intermetatarsal angle correction. First web space release can be recommended for severe deformity. Additionally, K-wire fixation (odds ratio (OR) 5.05 (95% confidence interval (CI) 1.21 to 24.39); p = 0.032) and the pre-operative hallux valgus angle (OR 2.20 (95% CI 1.11 to 4.73); p = 0.001) were shown to be factors affecting recurrence of hallux valgus after Ludloff osteotomy.
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NewsBot · Aug 20, 2013

The Ludloff osteotomy: a review of current concepts
Deborah A. Castaneda, Mark S. Myerson, Steven K. Neufeld
International Orthopaedics; August 2013

The Ludloff osteotomy is a technique option to address hallux valgus in patients with a moderately to significantly increased first-second intermetatarsal angle. The Ludloff osteotomy is an oblique osteotomy of the first metatarsal extending dorsal-proximal to plantar-distal when viewed in the sagittal plane. The dorsal-proximal portion of the metatarsal is cut with the saw while maintaining the plantar-distal surface intact. A screw is inserted across the proximal aspect of the osteotomy, then the osteotomy is extended across the plantar surface distally. The metatarsal is rotated around the axis of the screw to the desired correction. In order to perform the osteotomy correctly, the surgeon must not only effectively complete the nuances of the technique, but also understand the limitations and contraindications of the Ludloff osteotomy. This review of current concepts for the Ludloff osteotomy reviews recent literature as well as technique pearls and pitfalls in the application of this powerful osteotomy.
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NewsBot · Feb 25, 2015

A comparative study on the results of the modified Ludloff osteotomy for hallux valgus deformities with minimal erosion of the metatarsophalangeal joints in rheumatoid patients with non-rheumatoid patients
Il-Hoon Sung, Yoon-Kyoung Sung, Dong-Ryul Huh, and Sung-Jae Kim
Modern Rheumatology

Objectives: We aimed to compare the outcomes of joint preserving surgery for hallux valgus deformities with minimal erosion of the metatarsophalangeal (MTP) joint in rheumatoid patients with non-rheumatoid controls, and to determine the prognostic factors of recurrence in rheumatoid patients.

Methods: A total of 18 rheumatoid patients (20 feet, Group I) and 35 non-rheumatoid patients (39 feet, Group II) were included. The mean follow-up was 29.6 months. Radiographic and clinical outcomes were compared. To identify the prognostic factors for recurrences in rheumatoid patients, subgroup analyses were done in Group I.

Results: Most of the outcomes showed favorable results in both groups. However, Group II had better results in hallux valgus angle (HVA) (15.9° vs. 7.9°, p<0.001), and in sesamoid position (p=0.040) at final follow-up. Group I showed higher recurrence rate (50% vs. 0%). The final AOFAS score was better in Group II (82.1 vs. 90.7, p=0.014). The large preoperative HVA, non-performance of Akin osteotomy, insufficient reduction of sesamoid position were related to recurrence in rheumatoid patients.

Conclusions: Joint preserving surgery for hallux valgus deformities in rheumatoid forefoot deformity showed favorable results in mid-term follow-up, however, it should be warned of possible recurrent deformities.
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NewsBot · Nov 18, 2015

The influence of patient age and bone mineral density on osteotomy fixation stability after hallux valgus surgery: a biomechanical study
Stefan G. Hofstaetter et al
C;inical Biomechanics; Article in Press

Highlights
•First metatarsal osteotomy stability is important for expeditious healing
•Positive correlation between bone mineral density and bending stiffness
•Negative correlation between bone mineral density dorsal angulation
•No significant correlation between age and osteotomy stability measures
•High bone mineral density favors earlier weight bearing, active physical therapy
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Background
Oblique osteotomies of the first metatarsal are common surgical treatments for moderate to severe hallux valgus deformity. Osteotomy fixation integrity is important to minimize interfragment motion and maintain correction during healing, and our clinical observations suggest that patient age and bone quality affect fixation stability and ultimately the clinical outcome. Accordingly, this study correlated these patient factors with key mechanical measures of osteotomy angulation resistance in a cadaver hallux valgus correction model.

Methods
Standard Ludloff osteotomies were created in 31 fresh-frozen first metatarsals and fixed with two cannulated, dual-pitch headless screws. Each specimen underwent 1000 plantar-to-dorsal bending loads while monitoring bending stiffness and distal fragment dorsal angulation. Donor age and bone mineral density were then correlated with each mechanical measure at selected cycling increments.

Findings
We found significant positive correlation between bone mineral density and osteotomy fixation stiffness for all evaluated load cycles. Moderate negative correlation between bone density and angulation was identified, significant for load cycle 500. There was weak, nonsignificant negative correlation between donor age and osteotomy bending stiffness, with r ranging from -0.134 to -0.243 between the first and 1000th loads. Little correlation was demonstrable between age and angulation.

Interpretation
Because low bone density correlates with decreased osteotomy site stiffness and increased angulation under load, patient compliance and protected weight bearing in the early postoperative phase are particularly important if bone mineral density is exceptionally low. Correspondingly, patients with especially high bone mineral density may be considered candidates for earlier weight bearing and active physical therapy.
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NewsBot · Aug 29, 2017

Comparison of outcomes according to fixation technique following the modified Ludloff osteotomy for hallux valgus in patients with rheumatoid arthritis
Young-Hoon Jo et al
BMC Musculoskeletal Disorders 25 August 2017

Background
Clinical and radiological outcomes including fixation stability of osteotomy site were compared in rheumatoid arthritis (RA) patients who underwent modified Ludloff osteotomy to correct hallux valgus with osteotomy site fixation using two screws versus those who underwent additional fixation using a plate.

Methods
The fixation technique performed with two screws was used to fix the osteotomy sites following modified Ludloff osteotomy in 15 patients (15 feet, Group S), while the augmented plate fixation technique was used in 14 patients (16 feet, Group P). Surgical outcomes were analysed using the American Orthopedic Foot and Ankle Society (AOFAS) scores, and radiologic parameters measured before surgery and during follow-up examinations. To evaluate the stability of each osteotomy site fixation technique, the 1–2 inter-metatarsal angle (IMA) and angle of the altered margin of the lateral cortex (AMLC) were measured immediately and 6 weeks after surgery, and variations in the angles were compared. In addition, bone mineral density (BMD) values were compared between patients with correction loss at the osteotomy site and those with no loss of correction.

Results
No significant differences between groups were found for total AOFAS scores before surgery and at the final follow-up. However, significant differences were observed in the 1–2 IMA, beginning at 6 weeks postoperatively and continuing through the final follow-up. The 1–2 IMA and angle of AMLC measured immediately after and 6 weeks after surgery showed significantly greater variation in Group S than in Group P. In Group S, patients with correction loss (5 feet) at osteotomy site showed significantly lower BMD values than those with no loss of correction (10 feet). Despite the lower BMD values of patients in Group P than in Group S, a loss of correction did not occur in these patients.

Conclusions
Correction loss occurred at the osteotomy site within 6 weeks postoperatively in patients who underwent fixation using only the two-screw fixation technique following modified Ludloff osteotomy; such loss could be reduced using the augmented plate fixation technique even in patients with osteoporosis.
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NewsBot · Sep 24, 2017

Immediate weight-bearing after locking plate fixation of the Ludloff osteotomy
Steven Neufeld MD, John Marcel, MD
Foot & Ankle Orthopaedics September 18, 2017

Introduction/Purpose:
One of the more common and versatile osteotomies to correct moderate hallux valgus deformities is the Ludloff osteotomy. This oblique osteotomy is typically stabilized with screws and patients kept non-weight bearing until healed. Complications include malunion, nonunion and loss of correction, which can occur due to poor compliance with non- weight bearing protocols. Elderly, obese and physically weak patients can have difficulty remaining non-weight bearing. A novel anatomic-locking plate and fixation method was developed that allows immediate weight bearing after a Ludloff osteotomy. We analyzed the results of a consecutive cohort of patients who underwent a Ludloff osteotomy stabilized with this method. The cohort included all patients presenting with a moderate to severe hallux valgus deformities. Complications, radiographic & clinical outcomes were studied.

Methods:
In this IRB approved retrospective cohort study, we analyzed clinical & radiographic data of all Ludloff osteotomies performed between 2010 and 2015. Preoperative and postoperative data included Foot Function Index, intermetatarsal & hallux valgus angles, complications, callus formation & clinical outcomes. 395 feet in 350 patients were examined. 6 patients (2.1%) were male. 43 feet were excluded due to incomplete films and 21 were excluded due to screw fixation only; requiring restricted post- operative weightbearing protocols. Three surgeons performed the surgeries and review/analyses conducted by a senior orthopedic resident, uninvolved with the care of any of the patients. Indications included symptomatic hallux valgus deformities (intramedullary angle greater than 10°), failure of conservative treatment and normal preoperative range of motion. Exclusion criteria included 1st tarsometatarsal joint arthritis/instability, peripheral neuropathy, vascular disease and 1st metatarsophalangeal joint arthritis. Preoperative and postoperative radiographs were weightbearing. Patients discharged when comfortable in normal shoes.

Results:
At an average of 8 months postop (2 - 43 months), there was an average hallux valgus (HVA) correction angle correction of 7.6° (p<.0001) and intermetatarsal angle (IMA) correction of 21° from initial to final radiographs. Patients were discharged when comfortable in normal shoes. In the 15 feet (4.6%) who formed hypertrophic callus, there was loss of IMA of 2.3° (p<.0001) and HVA of 4.6° (p<.0001). Superficial wound infection or mild cellulitis was noted in 16 feet (4.9°); no deep infections. 15 (4.6%) feet had hardware removal due to prominent and/or broken screws. These were in older women with thin feet. There was only 1 nonunion & 8 mal-unions. An average foot function index (in 70 patients) of 9.5/100 indicated low pain and disability.

Conclusion:
The data from this large series of patients (395 osteotomies) supports the use of an immediate weight-bearing protocol for Ludloff osteotomies fixed with anatomic locking plates, including patients with osteopenic bone. All patients were allowed activities and weight bearing as tolerated during the post-operative period. There were relatively few complications including loss of correction or nonunion. Patients and surgeons can expect healing and complication rates similar to osteotomies fixed with screws and a non-weight-bearing post-operative protocol. Furthermore, because of the increased stability imparted by the anatomic locking plate, it would be a good option for revision bunion surgery.
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NewsBot · May 26, 2018

Karl Ludloff (1864-1945): An Inventive Orthopedic Surgeon, His Work and His Surgical Technique for the Correction of Hallux Valgus
Konstantinos Markatos, MD, BSc, MSc, PhD, Georgios Karaoglanis, MD, PhD, Christos Damaskos, MD, MSc, PhD, ...
Surgical Innovation May 20, 2018

The purpose of this article is to summarize the work and pioneering achievements in the field of orthopedic surgery of the German orthopedic surgeon Karl Ludloff. Ludloff had an impact in the diagnostics, physical examination, orthopedic imaging, and orthopedic surgical technique of his era. He was a pioneer in the surgical treatment of dysplastic hip, anterior cruciate ligament reconstruction, and hallux valgus. His surgical technique for the correction of hallux valgus, initially stabilized with plaster of Paris, remained unpopular among other orthopedic surgeons for decades. In the 1990s, the advent and use of improved orthopedic materials for fixation attracted the interest of numerous orthopedic surgeons in the Ludloff osteotomy for its ability to correct the deformity in all 3 dimensions, its anatomic outcomes, and its low recurrence rate and patient satisfaction.
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NewsBot · Aug 25, 2018

Clinical study of three-dimensional printed navigation template assisted Ludloff osteotomy in treatment of moderate and severe hallux valgus
Xu Y et al
Chinese Journal of Reparative and Reconstructive Surgery [01 Jul 2018, 32(7):906-911]

To explore the effectiveness and advantage of three-dimensional (3D) printed navigation templates assisted Ludloff osteotomy in treatment of moderate and severe hallux valgus.Between April 2013 and February 2015, 28 patients (28 feet) with moderate and severe hallux valgus who underwent Ludloff osteotomy were randomly divided into 2 groups ( n=14). In group A, the patients were treated with Ludloff osteotomy assissted with a 3D printed navigation template. In group B, the patients were treated with traditional Ludloff osteotomy. There was no significant difference in gender, age, affected side, and clinical classification between 2 groups ( P>0.05). The operation time and intraoperative blood loss were recorded. The ankle function of the foot at preoperation, immediate after operation, and last follow-up were assessed by the American Orthopedic Foot and Ankle Society (AOFAS) score. Besides, the X-ray film were taken to assess the hallux valgus angle (HVA), intermetatarsal angle (IMA), and the first metatarsal length shortening.All patients were followed up 18-40 months (mean, 26.4 months). The operation time and intraoperative blood loss in group A were significantly less than those in group B ( P<0.05). The HVA, IMA, and AOFAS scores in groups A and B at immediate after operaton and last follow-up were sinificantly improved when compared with preoperative values ( P<0.05); but no significant difference was found between at immediate after operation and at last follow-up ( P>0.05). No significant difference was found in HVA and IMA between group A and group B at difference time points ( P>0.05). There were significant differences in AOFAS score and the first metatarsal length shortening at immediate after operation and at last follow-up between 2 groups ( P<0.05). Except 1 case of metastatic metatarsalgia in group B, there was no other operative complications in both groups.3D printed navigation template assisted Ludloff osteotomy can provide accurate preoperative planning and intraoperative osteotomy. It is an ideal method for moderate and severe hallux valgus.
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